Assessing cosmetic results after breast conserving surgery

Error assessment of subjective estimates of linear breast dimensions versus the objective method

Objective

The study aimed to investigate the subjective method of estimating linear breast dimensions in comparison to the objective method.

Methods

The reproducibility and accuracy of the subjective method of estimating linear breast dimensions during a simplified breast shape analysis were examined. Four linear breast dimensions including the distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, distance from the nipple to the midline and under-breast width were evaluated based on subjective estimates. Images from 100 women with natural breasts and without any history of breast surgery were reviewed by two examiners three times each. The cases were obtained from a large database of breast images captured using the Vectra Camera System (Canfield Scientific Inc., USA). The subjective data were then compared with the objective linear data from the Vectra Camera System in the automated analysis. Statistical evaluation was conducted between the three repeated estimates of each examiner, between the two examiners and between the objective and subjective data.

Results

The intra-individual variations of the three subjective estimates were significantly greater in one examiner than in the other. This trend was consistent across all eight parameters in the majority of the comparisons of the standard deviations and variation coefficients, and the differences were significant in 14 out of 16 comparisons (p<0.05). Conversely, in the comparison between the subjective and objective data, the estimates were closer to the measurements in one examiner than the other. In contrast to the reproducibility observed, the assessment of the accuracy revealed that the examiner who previously presented with less reproducibility of the estimated data overall showed better accuracy in comparison to the objective data. The overall differences were inconsistent, with some being positive and others being negative. Regarding the distances from the sternal notch to the nipple and breast width, both examiners underestimated the values. However, the deviations were at different levels, particularly when considering the objective data from the Vectra Camera System as the gold standard data for comparison. Regarding the distance from the nipple to the inframammary fold, one examiner underestimated the distance, while the other overestimated it. An opposite trend was noted for the distance from the nipple to the midline. There were no differences in the estimates between the right and left sides of the breasts. The correlations between the measured and estimated distances were positive: as the objective distances increased, the subjective distances also increased. In all cases, the correlations were significant. However, the correlation for the breast width was notably weaker than that for the other distances.

Conclusions

The error assessment of the subjective method reveals that it varies significantly and unsystematically between examiners. This is true when assessing the reproducibility as well as the accuracy of the method in comparison to the objective data obtained with an automated system.

Evaluation of Intraoperative Volumetric Assessment of Breast Volume Using 3D Handheld Stereo Photogrammetric Device

Methods for assessing three-dimensional (3D) breast volume are becoming increasingly popular in breast surgery. However, the precision of intraoperative volumetric assessment is still unclear. Until now, only non-validated scanning systems have been used for intraoperative volumetric analyses. This study aimed to assess the feasibility, handling, and accuracy of a commercially available, validated, and portable device for intraoperative 3D volumetric evaluation. All patients who underwent breast surgery from 2020 to 2022 were identified from our institutional database. Intraoperative 3D volumetric assessments of 103 patients were included in this study. Standardized 3D volumetric measurements were obtained 3 months postoperatively to compare the intraoperatively generated volumetric assessment. All of the study participants were women with a mean age of 48.3 ± 14.7 years (range: 20-89). The mean time for intraoperative volumetric assessment was 8.7 ± 2.6 min. The postoperative 3D volumetric assessment, with a mean volume of 507.11 ± 206.29 cc, showed no significant difference from the intraoperative volumetric measurements of 504.24 ± 276.61 cc (p = 0.68). The mean absolute volume difference between the intraoperative simulations and postoperative results was 27.1 cc. Intraoperative 3D volumetric assessment using the VECTRA H2 imaging system seems to be a feasible, reliable, and accurate method for measuring breast volume. Based on this finding, we plan to investigate whether volumetric objective evaluations will help to improve breast symmetry in the future.

Evaluating the ability of an artificial-intelligence cloud-based platform designed to provide information prior to locoregional therapy for breast cancer in improving patient's satisfaction with therapy: The CINDERELLA trial

BACKGROUND

Breast cancer therapy improved significantly, allowing for different surgical approaches for the same disease stage, therefore offering patients different aesthetic outcomes with similar locoregional control. The purpose of the CINDERELLA trial is to evaluate an artificial-intelligence (AI) cloud-based platform (CINDERELLA platform) vs the standard approach for patient education prior to therapy.

METHODS

A prospective randomized international multicentre trial comparing two methods for patient education prior to therapy. After institutional ethics approval and a written informed consent, patients planned for locoregional treatment will be randomized to the intervention (CINDERELLA platform) or controls. The patients in the intervention arm will use the newly designed web-application (CINDERELLA platform, CINDERELLA APProach) to access the information related to surgery and/or radiotherapy. Using an AI system, the platform will provide the patient with a picture of her own aesthetic outcome resulting from the surgical procedure she chooses, and an objective evaluation of this aesthetic outcome (e.g., good/fair). The control group will have access to the standard approach. The primary objectives of the trial will be i) to examine the differences between the treatment arms with regards to patients' pre-treatment expectations and the final aesthetic outcomes and ii) in the experimental arm only, the agreement of the pre-treatment AI-evaluation (output) and patient's post-therapy self-evaluation.

DISCUSSION

The project aims to develop an easy-to-use cost-effective AI-powered tool that improves shared decision-making processes. We assume that the CINDERELLA APProach will lead to higher satisfaction, better psychosocial status, and wellbeing of breast cancer patients, and reduce the need for additional surgeries to improve aesthetic outcome.

Exploring natural breast symmetry in the female plastic surgical patient population

Background

Breast symmetry remains a challenging quality to measure. The question arises of how much baseline breast symmetry exists in the female plastic surgical patient population.

Material and methods

Several linear dimensional assessments were collected based on a retrospective analysis of objective data of women with natural breasts, who presented for an initial consultation in a plastic surgical clinic and were measured with the 3D Vectra Camera by the company Canfield Scientific Inc., U.S.A. The first 100 cases were extracted from the large database in alphabetical order. The nipple positions were examined, including the following linear dimensions: distances from the jugulum to the nipple, from the nipple to the inframammary fold, and from the nipple to midline. Furthermore, the under-breast widths were obtained.

Results

The objective three-dimensional imaging method determined that all patients had some degree of asymmetry. The linear distances from the jugulum and midline to the nipple revealed that the measurements were larger on the left side. However, the nipple to the inframammary fold measurements were roughly the same. In the sample of plastic surgical patients, the average distance between the jugulum and nipple was around 20 cm, the distance between the nipple and inframammary fold was around 6.5 cm, the distance between the nipple and midline was around 10 cm, and the under-breast width was around 13 cm. On average, the jugulum-nipple distance on the right side was 19.9±2.3 cm and 20.1±2.4 cm on the left side. The distance between the nipple and the inframammary fold was 6.4±1.1 cm, revealing a similar distribution on both sides. The mean distance from the nipple to the midline was much larger on the left side of the body at 10.0±1.2 cm than on the right side at 9.4±1.3 cm. The under-breast width on the right side was slightly larger than the left side, with measurements of 13.4±1.8 cm versus 13.2±1.7 cm.

Conclusion

Breast dimensions can be described comprehensively by an objective three-dimensional imaging process, which can detect asymmetry in all patients. The differences related to the nipple position were larger on the left side than the right regarding the distances from the jugulum and particularly the midline to the nipple, which seems to be of special importance, but not from the nipple to the inframammary fold. The linear measurements for the distances from the jugulum and the midline to the nipple are essential to accurate symmetry assessments and form an aesthetic triangle of the breast, which is a new term and the key to a simplified shape analysis.

Evaluation of Vectra® XT 3D Surface Imaging Technology in Measuring Breast Symmetry and Breast Volume

BACKGROUND

Breast symmetry is an essential component of breast cosmesis. The Harvard Cosmesis scale is the most widely adopted method of breast symmetry assessment. However, this scale lacks reproducibility and reliability, limiting its application in clinical practice. The VECTRA® XT 3D (VECTRA®) is a novel breast surface imaging system that, when combined with breast contour measuring software (Mirror®), aims to produce a more accurate and reproducible measurement of breast contour to aid operative planning in breast surgery.

OBJECTIVES

This study aims to compare the reliability and reproducibility of subjective (Harvard Cosmesis scale) with objective (VECTRA®) symmetry assessment on the same cohort of patients.

METHODS

Patients at a tertiary institution had 2D and 3D photographs of their breasts. Seven assessors scored the 2D photographs using the Harvard Cosmesis scale. Two independent assessors used Mirror® software to objectively calculate breast symmetry by analysing 3D images of the breasts.

RESULTS

Intra-observer agreement ranged from none to moderate (kappa - 0.005-0.7) amongst the assessors using the Harvard Cosmesis scale. Inter-observer agreement was weak (kappa 0.078-0.454) amongst Harvard scores compared to VECTRA® measurements. Kappa values ranged 0.537-0.674 for intra-observer agreement (p < 0.001) with Root Mean Square (RMS) scores. RMS had a moderate correlation with the Harvard Cosmesis scale (r_s = 0.613). Furthermore, absolute volume difference between breasts had poor correlation with RMS (R² = 0.133).

CONCLUSION

VECTRA® and Mirror® software have potential in clinical practice as objectifying breast symmetry, but in the current form, it is not an ideal test.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial

Introduction

Breast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure.

Methods

A randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the “reshaping” group (closure of excision defect with mobilised breast tissue; n = 124) and to the “control” group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ).

Results

There were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of “good” or “excellent” by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001).

Conclusions

Simple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.

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Breast-conserving cancer surgery can lead to unsatisfactory cosmetic outcomes.

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Simple oncoplastic closure improves long-term cosmetic outcomes.

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Objective and subjective cosmetic outcomes of oncoplastic closure are correlated.

[Interest of systematic shavings to reduce reoperation in breast-conserving surgery of breast cancer]

OBJECTIVE

The INCa and HAS have developed quality and safety indicators for care specific to breast cancer. Among these, in the conservative surgery of this cancer includes the reoperation rate: target˂10%, alert>20%. The main objective of our study was to evaluate whether the practice of systematic recuts still called "shaving" would meet the objectives of the indicators.

METHODS

Observational, retrospective, single-center study over two years in a regional referral center. Two groups of patients were compared: one with "shaving" and one without (no shaving or oriented shaving).

RESULTS

In total, 381 patients were operated on, including 48 (12.6%) with shaving and 333 (87.4%) without. Revision rates for damaged margins were 18.75% (9/48) in the shaving group which met the quality criterias vs. 23.7% (79/333) which did not satisfy them; P=0.4. Furthermore, the rate of discovery of occult sites on recuts was higher in the shaving group: 22.9% (11/48) vs. 9.9% (33/333); P=0.02. In the shaving group, 10.4% (5/48) of the patients were resected again for damaged margins for the initial cancer vs. 18.6% (62/333) in the group without shaving; P=0.23.

CONCLUSION

Our study confirms the interest of performing "shaving" to meet the requirements of the INCa and HAS quality criteria. The absence of systematic cross-sectioning leads to the risk of not recognizing the existence of occult sites. However, the discovery of occult cancers does not significantly reduce the rate of repeat surgery.

Reliability of the BCCT.core software in evaluation of breast cosmesis - A systematic review

Breast cancer conservative treatment software (BCCT.core) has the potential to provide objective results using digital photographs, thus increasing the reliability, limiting the subjective interpretation and standardising the evaluation of breast cosmesis in patients. The aim of this systematic review was to summarise the empirical evidence regarding the agreement between the BCCT.core and other methods used by health professionals and patients to assess breast cosmesis. The Ovid MEDLINE, Embase, CINAHL, PsycINFO and Scopus databases were systematically searched for studies comparing the agreement between BCCT.core and other methods used to assess breast cosmesis. A total of 14 studies involving 2703 patients were included in the review. In studies where patients undertook self-assessment, the percentage agreement ranged from 69.2% to 74.8% and the kappa values ranged from slight (k = 0.12) to fair agreement. There was a low correlation between the BCCT.core and the Harvard scale when patients assessed cosmetic outcomes using photographs of their breasts (r = 0.165). A 75% and 42.8% agreement was reported in studies where clinicians assessed breast cosmesis by directly visualising the patients' breasts and photographs, respectively. Assessment of breast cosmesis by the expert panel using patient photographs reported a percentage agreement ranging from 25% to 83%. The results of this systematic review demonstrated an overall agreement of fair to moderate between the BCCT.core and the subjective scales used to assess breast cosmesis. However, clinician experience and patient values should be considered in clinical decision-making.

Breast conservation and axillary management after primary systemic therapy in patients with early-stage breast cancer: the Lucerne toolbox

Primary systemic therapy is increasingly used in the treatment of patients with early-stage breast cancer, but few guidelines specifically address optimal locoregional therapies. Therefore, we established an international consortium to discuss clinical evidence and to provide expert advice on technical management of patients with early-stage breast cancer. The steering committee prepared six working packages to address all major clinical questions from diagnosis to surgery. During a consensus meeting that included members from European scientific oncology societies, clinical trial groups, and patient advocates, statements were discussed and voted on. A consensus was reached in 42% of statements, a majority in 38%, and no decision in 21%. Based on these findings, the panel developed clinical guidance recommendations and a toolbox to overcome many clinical and technical requirements associated with the diagnosis, response assessment, surgical planning, and surgery of patients with early-stage breast cancer. This guidance could convince clinicians and patients of the major clinical advancements purported by primary systemic therapy, the use of less extensive and more targeted surgery to improve the lives of patients with breast cancer.

How to Optimize Aesthetics for the Partial Mastectomy Patient

Aesthetic concern is one of the main driving forces behind the popularity of the oncoplastic approach to breast conservation therapy. Oncoplastic options at the time of lumpectomy include volume replacement techniques such as flaps and volume displacement techniques such as the oncoplastic reduction. These techniques can be employed to ensure preservation of breast shape and contour, size and symmetry, inframammary fold position, and position of the nipple-areola complex. The importance of aesthetic outcomes is not only to improve overall patient satisfaction but also to minimize the need for revisional surgeries for shape and symmetry. The purpose of this review is to discuss ways to optimize the aesthetic result and to review the evidence behind aesthetic outcomes.

Radiofrequency Ablation of the Surgical Bed After Lumpectomy in Breast-conserving Surgery

INTRODUCTION

Obtaining tumor-free margins during breast conservative surgery (BCS) is essential to avoid local recurrence and frequently requires reoperation. Radiofrequency ablation (RFA) of surgical margins after lumpectomy seems to be a helpful tool to avoid reoperations, but evidence is insufficient. This study analyzes the efficacy and safety of RFA after BCS to obtain free surgical margins.

METHODS

Non-randomized experimental study performed in an intervention group of 40 patients assigned to receive RFA after lumpectomy and successive resection of surgical margins, and a historical control group of 40 patients treated with BCS alone. In the intervention group, the RFA effect on tumor cell viability in the surgical margins was analyzed. Also, reoperation rate, complications and cosmetic results were compared in both groups.

RESULTS

A total of 240 excised margins were analyzed after RFA, obtaining a high number of tumor-free margins. Compared to the control group, the reoperation rate decreased significantly (0% vs 12%; P=.02), without differences in terms of postoperative complications (10% vs 5%; P=.67) or cosmetic results (excellent or good 92.5% vs 95%; P=.3).

CONCLUSIONS

RFA after lumpectomy is a reliable, safe and successful procedure to obtain tumor-free surgical margins and to decrease the reoperation rate without affecting complications or compromising cosmetic results.

kOBCS©: a novel software calculator program of the Objective Breast Cosmesis Scale (OBCS)

PURPOSE

The Objective Breast Cosmesis Scale (OBCS) is an objective method that documents the aesthetic changes in breast cancer patients. This work evaluates the kOBCS© software (http://www.kobcs.info) which simplifies the estimation of the OBCS values.

METHODS

Five schematic drawings were photographed and imported into the kOBCS©. Thirty photos of breast cancer patients were imported into kOBCS©; 20 users (experts and non-experts) evaluated the photographs on two different settings. Subjective evaluation was performed using the Harvard breast cosmesis scale.

RESULTS

There was a highly significant correlation between the OBCS values based on hand measurements and the values estimated by kOBCS© (r = 0.997, P < 0.001). Agreement among the users using the kOBCS© was strong with high statistical significance (ICC = 0.846, P < 0.001, 95% CI 0.774-0.910, Cronbach's alpha = 0.991). Results of the subjective analyses and mean OBCS values as estimated by kOBCS© correlated significantly (r = 0.961, P < 0.001).

CONCLUSIONS

The kOBCS© is a reliable and reproducible easy-to-use software for reporting breast cosmesis following breast-conserving therapy.

Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial

PURPOSE

In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome.

METHODS AND MATERIALS

Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume).

RESULTS

One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast.

CONCLUSIONS

PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.

Satisfaction with the Aesthetic Effect and Quality of Life for Women after Breast Conserving Therapy (BCT)-Preliminary Research

All methods of breast cancer treatment may potentially lead to breast deformities, which are often associated with the reduced mental well-being of patients. Breast conserving therapy (BCT) is commonly used, and its core element is breast conserving surgery (BCS).The aim of this study was to determine the level of satisfaction with the aesthetic outcome of surgery and quality of life (QoL) of breast cancer patients undergoing BCT in a longitudinal study performed three months, six months and 12 months after surgery. This longitudinal observational study was carried out on a group of 91 women. The Breast-Q^TM BCT 1.0 questionnaire was used in this study. Before surgery, patients assessed their satisfaction with the appearance of their breasts (SwB) at an average level of M = 56.0. Satisfaction with the aesthetic outcome (SwO) of BCS was highest among all patients three months after surgery (M = 63.0). The mean score in the sub-scale of psychosocial well-being (Psycho-soc W-B) before surgery was M = 62.0, while in the subsequent periods of the study, it was higher. The mean score for physical well-being (Physical W-B) before surgery was M = 69.92; and in the subsequent study periods, it was lower. The level of patient satisfaction with the outcome of the surgery and the QoL related to health do not differ significantly in post-operative observation. QoL in terms of psychosocial functioning in patients undergoing BCT is significantly higher 12 months after surgery compared to the pre-operative period. Patient satisfaction with the BCS aesthetic outcome is positively related to the evaluation of QoL in terms of psychosocial functioning.

Evolution, current challenges, and future possibilities in the objective assessment of aesthetic outcome of breast cancer locoregional treatment

The Breast Cancer overall survival rate has raised impressively in the last 20 years mainly due to improved screening and effectiveness of treatments. This increase in survival paralleled the awareness over the long-lasting impact of the side effects of treatments on patient quality of life, emphasizing the motto “a longer but better life for breast cancer patients”. In breast cancer more strikingly than in other cancers, besides the side effects of systemic treatments, there is the visible impact of surgery and radiotherapy on patients’ body image. This has sparked interest on the development of tools for the aesthetic evaluation of Breast Cancer locoregional treatments, which evolved from manual, subjective approaches to computerized, automated solutions. However, although studied for almost four decades, past solutions were not mature enough to become a standard.

Recent advancements in machine learning have inspired trends toward deep-learning-based medical image analysis, also bringing new promises to the field of aesthetic assessment of locoregional treatments. In this paper, a review and discussion of the previous state-of-the-art methods in the field is conducted and the extracted knowledge is used to understand the evolution and current challenges. The aim of this paper is to delve into the current opportunities as well as motivate and guide future research in the aesthetic assessment of Breast Cancer locoregional treatments.

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Past, present and future of objective assessment of aesthetic outcome of breast cancer treatments.

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Critical discussion of the role and impact of deep-learning-based methodologies in the field.

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Recommendation for future efforts in the objective assessment of aesthetic outcome of breast cancer treatments.

A prospective comparison of subjective and objective assessments of cosmetic outcomes following breast brachytherapy

Purpose

We evaluated agreement between subjective and objective methods of cosmesis scoring in an accelerated partial breast irradiation (APBI) cohort.

Material and methods

Consecutive women treated with APBI using interstitial brachytherapy reported for clinical follow-up every 6 months. Single cross-sectional assessment of the breast cosmesis was done by a radiation oncologist (subjective method) using Harvard scale and by photographic assessment using BCCT.core (Breast Cancer Conservative Treatment. Cosmetic results, version 3.1) software (objective method) at 18-36 months post-APBI. The agreement between subjective and objective methods for the overall score as well as individual subjective/objective subdomains was computed using kappa statistics. ANOVA was used to test the correlation between objective indices and subjective subdomains.

Results

The agreement between the subjective (physician) and objective assessment was good with a kappa of 0.673. Overall, 77 (98.7%) patients were satisfied with the overall outcomes of breast conservation therapy. The kappa agreement between physician and patient scoring was 0.457 (95% CI: 0.240-0.674). Among the subjective subdomains, location of the nipple areola complex (NAC) had good agreement with both the overall subjective and objective score, with the kappa of 0.778 and 0.547, respectively. In the objective indices, BCE (breast compliance evaluation), LBC (lower breast contour), and UNR (unilateral nipple retraction) correlated significantly with the subjective subdomains: location of the NAC, breast size, and shape (p < 0.05 for all indices).

Conclusions

Good agreement exists for overall cosmetic outcomes measured by subjective and objective methods. Location of the NAC, breast size and shape are the most important parameters determining cosmetic outcomes irrespective of the method of assessment.

Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core)

Background

Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones.

Methods

Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared.

Results

Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6-90 mm) with a resection weight of 245.8 g (16-1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05).

Conclusions

Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones.

Nonrigid reconstruction of 3D breast surfaces with a low-cost RGBD camera for surgical planning and aesthetic evaluation

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A nonrigid 3D breast surface reconstruction pipeline running on a standard PC taking a noisy RGBD input video from a Kinect-style camera is proposed.

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Pairwise nonrigid ICP is extended to the multi-view case incorporating soft mobility constraints in areas of non-overlap.

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Shortest distance correspondences as a new technique for data association are shown to lead to consistently better alignment.

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The method is able to reconstruct clinical-quality surface models in spite of varying degrees of postural sway during data capture.

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Landmark and volumetric quantitative validation in metric units demonstrate improved reconstruction quality on par with the gold standard and superior to a competing method.

Accounting for 26% of all new cancer cases worldwide, breast cancer remains the most common form of cancer in women. Although early breast cancer has a favourable long-term prognosis, roughly a third of patients suffer from a suboptimal aesthetic outcome despite breast conserving cancer treatment. Clinical-quality 3D modelling of the breast surface therefore assumes an increasingly important role in advancing treatment planning, prediction and evaluation of breast cosmesis. Yet, existing 3D torso scanners are expensive and either infrastructure-heavy or subject to motion artefacts. In this paper we employ a single consumer-grade RGBD camera with an ICP-based registration approach to jointly align all points from a sequence of depth images non-rigidly. Subtle body deformation due to postural sway and respiration is successfully mitigated leading to a higher geometric accuracy through regularised locally affine transformations. We present results from 6 clinical cases where our method compares well with the gold standard and outperforms a previous approach. We show that our method produces better reconstructions qualitatively by visual assessment and quantitatively by consistently obtaining lower landmark error scores and yielding more accurate breast volume estimates.

Multi-institutional evaluation of the reproducibility and the accuracy of the objective breast cosmesis scale

PURPOSE

The aim of the present work is to assess the Objective Breast Cosmesis Scale (OBCS) in a patient cohort that was treated in two hospitals. Their treatment-related cosmetic changes were recorded on nonstandardized photographs.

METHODS AND MATERIALS

Nineteen female patients were enrolled in two radiation oncology centers (Nice, France, and Perugia, Italy). All patients had undergone breast-conserving surgery (BCS) and received adjuvant accelerated partial breast irradiation using interstitial fractionated multicatheter high-dose-rate brachytherapy. One photograph before and another after accelerated partial breast irradiation was taken for each patient to record changes in breast cosmesis. Using the OBCS, before and after photographs were analyzed by measuring distances between anatomic features. OBCS scores from four doctors (two males [one radiation oncologist and one post-grad trainee] and two females [one radiation oncologist and one post-grad trainee]) were compared.

RESULTS

Agreement was high between trainees and specialist, and males and females before and after treatment. The intraclass correlation coefficient ranged from 0.867 to 0.950 before treatment and from 0.876 to 0.952 afterward. The coefficient of variation ranged from 12% to 26.5% before treatment, and from 13% to 21.4% afterward.

CONCLUSIONS

The OBCS is easy, time-efficient, reproducible, cost-effective, and reliable. Its potential practical applications merit further investigation in future studies.

The value of 3D images in the aesthetic evaluation of breast cancer conservative treatment. Results from a prospective multicentric clinical trial

PURPOSE

BCCT.core (Breast Cancer Conservative Treatment. cosmetic results) is a software created for the objective evaluation of aesthetic result of breast cancer conservative treatment using a single patient frontal photography. The lack of volume information has been one criticism, as the use of 3D information might improve accuracy in aesthetic evaluation. In this study, we have evaluated the added value of 3D information to two methods of aesthetic evaluation: a panel of experts; and an augmented version of the computational model - BCCT.core3d.

MATERIAL AND METHODS

Within the scope of EU Seventh Framework Programme Project PICTURE, 2D and 3D images from 106 patients from three clinical centres were evaluated by a panel of 17 experts and the BCCT.core. Agreement between all methods was calculated using the kappa (K) and weighted kappa (wK) statistics.

RESULTS

Subjective agreement between 2D and 3D individual evaluation was fair to moderate. The agreement between the expert classification and the BCCT.core software with both 2D and 3D features was also fair to moderate.

CONCLUSIONS

The inclusion of 3D images did not add significant information to the aesthetic evaluation either by the panel or the software. Evaluation of aesthetic outcome can be performed using of the BCCT.core software, with a single frontal image.

Skin-reducing oncoplasty: A new concept and classification in breast cancer surgery

BACKGROUND AND OBJECTIVES

Breast-conserving surgery and skin-sparing mastectomy are nowadays widely accepted as the standard of care in selected patients with early breast cancer. After an accurate review of the literature, it appeared that no ordered list of the numerous techniques described for conservative breast surgery has been established so far. The aim of this study was to develop a simple classification of the different skin incision patterns that may be used in breast surgery.

METHODS

A systematic review of the English literature was conducted using the PubMed database to identify all the articles reporting breast-conserving surgery and skin-sparring mastectomy techniques up to the 31st of December 2016.

RESULTS

Among the 1426 titles identified, 230 were selected for review. Based on the reviewed papers, the skin-reducing oncoplasty incision pattern (SROIP) classification was elaborated.

CONCLUSIONS

Breast cancer surgery should nowadays optimise aesthetic outcomes by improving the final breast shape, volume and scar location. This may be achieved using different procedures that we grouped together under the term skin-reducing oncoplasty (SRO). Depending on the breast cancer location, the SROIP classification helps in the choice of the best technique to be used.

A Regression Model for Predicting Shape Deformation after Breast Conserving Surgery

Breast cancer treatments can have a negative impact on breast aesthetics, in case when surgery is intended to intersect tumor. For many years mastectomy was the only surgical option, but more recently breast conserving surgery (BCS) has been promoted as a liable alternative to treat cancer while preserving most part of the breast. However, there is still a significant number of BCS intervened patients who are unpleasant with the result of the treatment, which leads to self-image issues and emotional overloads. Surgeons recognize the value of a tool to predict the breast shape after BCS to facilitate surgeon/patient communication and allow more educated decisions; however, no such tool is available that is suited for clinical usage. These tools could serve as a way of visually sensing the aesthetic consequences of the treatment. In this research, it is intended to propose a methodology for predict the deformation after BCS by using machine learning techniques. Nonetheless, there is no appropriate dataset containing breast data before and after surgery in order to train a learning model. Therefore, an in-house semi-synthetic dataset is proposed to fulfill the requirement of this research. Using the proposed dataset, several learning methodologies were investigated, and promising outcomes are obtained.

The potential role of three-dimensional surface imaging as a tool to evaluate aesthetic outcome after Breast Conserving Therapy (BCT)

PURPOSE

To establish whether objective measurements of symmetry of volume and shape using three-dimensional surface imaging (3D-SI) can be used as surrogate markers of aesthetic outcome in patients who have undergone breast conserving therapy (BCT).

METHODS

Women who had undergone unilateral BCT in the preceding 1-6 years were invited to participate. Participants completed a satisfaction questionnaire (BREAST-Q) and underwent 3D-SI. Volume and surface symmetry were measured on the images. Assessment of aesthetic outcome was undertaken by a panel of clinicians. The Kruskal-Wallis test was used to assess the relationship between volume and shape symmetry measurements with the panel score. Spearman's rho correlations were used to assess the relationship between the measurements and patient satisfaction.

RESULTS

200 women participated. Median volume symmetry was 87% (IQR 78-93) and shape symmetry was 5.9 mm (IQR 4.2-8.0). The participants were grouped according to panel assessment of aesthetic outcome (poor, fair, good, excellent) and the median volume and shape symmetry was calculated for each group. Volume symmetry significantly differed between the groups. Post hoc pairwise comparisons demonstrated that these differences existed between panel scores of fair versus good and good versus excellent. Median shape symmetry also differed according to patient panel groups with four significant pairwise comparisons between poor versus good, poor versus excellent, fair versus good and fair versus excellent. There was a significant but weak correlation of both volume symmetry and surface asymmetry with BREAST-Q scores (correlation coefficients 0.187 and -0.229, respectively).

CONCLUSION

Breast volume and shape symmetry are both associated with panel assessment scores and patient satisfaction. The objective volume and shape symmetry measures were strongly associated with panel assessment scores, such that a 3D-SI tool could replace panel assessment as a faster and more objective method of evaluating aesthetic outcomes.

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement

PURPOSE

To develop an atlas for oncoplastic surgery (OPS) with template dissection techniques via anatomically ideal incisions for breast conservation surgery. The evolution of breast conservation techniques has evolved from placing an incision directly over the lesion to the incorporation of a thoughtful decision making process utilizing oncoplastic surgical (OPS) techniques to combining OPS with incision placement in anatomically advantageous sites. The high survival rates of breast cancer and effect of breast surgery on quality of life reinforce emphasis of optimal oncologic as well as aesthetic outcome. OPS results in greater patient satisfaction, fewer surgeries, and is oncologically safe. Today's breast surgeon is tasked with optimizing both oncologic and aesthetic outcomes.

METHODS

Presentation of reproducible dissection techniques and incision placement strategies to afford surgeons a step-by-step approach of OPS via anatomically ideal incisions in breast conservation surgery.

RESULTS

Demonstration of reproducible techniques to facilitate the decision making process of optimal breast conservation surgery, eliminate knowledge gaps for surgeons, optimize outcome for individuals undergoing breast conservation surgery, and decrease disparity of care.

CONCLUSION

Adoption of OPS techniques utilizing an anatomically ideal incision in breast conservation surgery is a feasible and reproducible practice for breast surgeons. Application of these techniques results in maintained optimal shape, size, and contour without the typical overlying skin envelope scars. OPS techniques performed under the skin envelope result in expected OPS oncologic and aesthetic outcomes with the addition of the resulting scar(s) in anatomically discrete position(s).

Ultrasound-guided breast-conserving surgery for early-stage palpable and nonpalpable invasive breast cancer: decreased excision volume at unchanged tumor-free resection margin

Ultrasound guidance (USG) during breast-conserving surgery improves tumor-free surgical resection margins. The objective of this study was to evaluate whether USG reduces resection volumes without compromising margin status. 134 patients with palpable or nonpalpable T1-2N0-1 invasive breast cancer were treated with USG and compared with a historical reference control group (CON) consisting of palpation-guided (PAG) or wire-guided localization (WIG) breast-conserving surgery. Primary outcomes were excess resection volume and clear margin status, and secondary outcome was re-excision rate. 66 patients underwent USG. In the CON group (n = 68), PAG was performed in 24 (35 %) and WIG in 44 (64 %) patients. Median excision volume [39 (IQR 20-66) vs 56 (38-94) cm(3); p = 0.001] and median calculated resection ratio [1.7 (1.0-2.9) vs 2.8 (1.4-4.6) (p = 0.005)] were significantly smaller in the USG than in the CON group. Median minimal distance to the resection margin [4 mm (IQR 2-5 mm) vs 2 mm (1-4 mm), p = 0.004] was significantly larger. Clear resection margins were achieved in 58 of the USG patients (88 %) and in 58 of the CON patients (86 %) (p = 0.91); this was true in patients with palpable as well as nonpalpable lesions. Reexcision was needed in 6.1 and 7.2 % respectively. Relative risk for re-excision in the USG group was 0.82 (95 % CI 0.23-2.93). In patients with palpable and nonpalpable breast cancers, USG allows for lower excision volume and reduced resection of healthy breast tissue, without increased re-excision rate.

The breast cancer conservative treatment. Cosmetic results - BCCT.core - Software for objective assessment of esthetic outcome in breast cancer conservative treatment: A narrative review

BACKGROUND AND OBJECTIVE

Cosmetic outcome of breast cancer conservative treatment (BCCT) remains without a standard evaluation method. Subjective methods, in spite of their low reproducibility, continue to be the most frequently used. Objective methods, although more reproducible, seem unable to translate all the subtleties involved in cosmetic outcome. The breast cancer conservative treatment cosmetic results (BCCT.core) software was developed in 2007 to try to overcome these pitfalls. The software is a semi-automatic objective tool that evaluates asymmetry, color differences and scar visibility using patient's digital pictures. The purpose of this work is to review the use of the BCCT.core software since its availability in 2007 and to put forward future developments.

METHODS

All the online requests for BCCT.core use were registered from June 2007 to December 2014. For each request the department, city and country as well as user intention (clinical use/research or both) were questioned. A literature search was performed in Medline, Google Scholar and ISI Web of Knowledge for all publications using and citing "BCCT.core".

RESULTS

During this period 102 centers have requested the software essentially for clinical use. The BCCT.core software was used in 19 full published papers and in 29 conference abstracts.

CONCLUSIONS

The BCCT.core is a user friendly semi-automatic method for the objective evaluation of BCCT. The number of online requests and publications have been steadily increasing turning this computer program into the most frequently used tool for the objective cosmetic evaluation of BCCT.

Preoperative chemotherapy for T2 breast cancer is associated with improved surgical outcome

BACKGROUND

The aim of this study is to compare the clinical outcome in T2 breast cancer patients who underwent preoperative chemotherapy (PC) and who did not. The study also tried to define a subgroup of patients, who are more beneficial after PC in terms of lower re-excision rates, better cosmetic results and local recurrence free survival.

MATERIALS AND METHODS

251 consecutive patients treated for nonmetastatic T2 invasive breast cancer were analyzed retrospectively. Of those; 141 underwent primary surgery (PS) followed by chemotherapy, whereas 110 were treated with combination of PC and surgery.

RESULTS

The patients who were treated with PC had a significantly higher incidence of negative margins and lower rate of re-excision (5% vs. 16%, p = 0.02). Of all patients attempted breast conserving surgery (BCS), patients in the PC group were more likely to undergo BCS as their definitive operation compared to patients with PS group (BCS rates; PC group: 99% vs. PS group: 92%, p = 0.05). Multifocal disease (OR: 7, 95% Cl, 2.7-18.4, p = 0.0001) and PC (OR = 0.2; 95% CI, 0.06-0.72, p = 0.01) were factors associated with margin positivity in patients treated with BCS. There was no statistically significant difference in 5 year local-recurrence free survival rates between 2 groups.

CONCLUSIONS

Our study shows that PC significantly decreases the re-excision in patients undergoing BCS with primary T2 breast tumors. This data suggests that any patient with a tumor greater than 2 cm might be considered for PC to increase BCS success with final negative margins.

Mammographic and Ultrasonographic Findings of Oxidized Regenerated Cellulose in Breast Cancer Surgery: A 5-Year Experience

BACKGROUND

The purpose of this study was to describe the ultrasonographic (US) and mammographic (MX) findings in patients who underwent breast-conserving surgery followed by oxidized regenerated cellulose (ORC) implantation in the surgical cavity and their size variations in follow-up.

MATERIALS AND METHODS

We retrospectively reviewed 417 MX and 743 US images performed between January 2009 and January 2014 for 262 women who underwent breast-conserving surgery. All patients underwent US, only 203 women underwent MX examination.

RESULTS

In 170 of 262 patients, US examinations showed abnormal findings. Three main US patterns were identified: (1) complex masses: well-encapsulated ipoisoechoic lesions with circumscribed margins with internal hyperechoic nodules (56%); (2) hypoanechoic lesions without internal hyperechoic nodules (24%); and (3) completely anechoic collections (20%). Moreover, Doppler ultrasound examination was performed on all of the patients. In 95 of 203 patients, MX examinations showed abnormalities. Four main MX patterns were identified: (1) round or oval opacity with circumscribed margins (58%); (2) round or oval opacity with indistinct or ill-defined margins (17%); (3) irregular opacity with indistinct or spiculated margins (9%); and (4) architectural distortion or focal asymmetry (15%). Most of the lesions showed a decrease in size at US and MX follow-up examination and the decrease was statistically significant (P < .01).

CONCLUSION

When applied to the surgical residual cavity, ORC aids to control local hemorrhage and reduce the risk of postoperative infections, but can lead to alterations in surgical scar. Thus, knowledge of the radiological findings might allow avoidance of misdiagnosis of tumor recurrence or unnecessary diagnostic examinations.